Antimicrobial Prescribing Policy Research Articles

FTP4.1 Compliance With Antimicrobial Prescribing Guideline Recommendations

Abstract Aims Due to concerns regarding the quality of antimicrobial prescribing in the General Surgery department at a District General Hospital, a prospective quality improvement project was undertaken to guide local antimicrobial stewardship. To assess the compliance of the General Surgery department with local antimicrobial prescribing guidelines and policies, and recommendations in the BNF and electronic medicines compendium (EMC). The aim was to evaluate the extent of change in compliance of the General Surgery junior doctors during after intervention. Methodology Prospectively collected data on the patients admitted and started on antimicrobial agents over two 3-week periods under the General Surgery department. Educational interventions were initiated in the interval between the periods of data collection. Results 91 patients were audited in Cycle 1 with a median age of 57 (9-93) years including 36 males and 55 females. Cycle 2 involved 89 patients with a median age of 60 (9-87) with 48 males and 41 females. After intervention, there was an increase in correct prescribing regime (51.6 to 56.2%), correct dose (91.2 to 98.9%), correct frequency (59.3 to 79.8%), and correct duration; when included (78.8 to 83.3%). There was a decrease in the duration being included on the prescription (36.3 to 33.7%). The increases in correct antimicrobial dosing and correct antimicrobial frequency prescriptions were statistically significant at p ≤ 0.05. Conclusion Areas for improvement in the compliance to prescribing guidelines in the department could be influenced successfully through appropriate intervention. The audit highlighted particular areas to be targeted by education.

Optimizing Antimicrobial Prescribing in Dentistry in India – From Policy to Practice

Introduction: It is estimated that in total, dentists prescribe 10% of all antimicrobials prescribed, and there is evidence of inappropriate use. Although National guidelines for antimicrobial prescribing and framing antibiotic policy are available for broad medical specialities, they don’t include various specialities in clinical dentistry. This guidance has been developed to promote judicious antimicrobial prescribing and antimicrobial stewardship in clinical dentistry in India. Methods: This policy was developed by the members of Antimicrobial Stewardship Practice Committee in consultation with the Dental practitioners in various specialities in dentistry. Results & Discussion: The AMSP committee issued a policy for the year 2021-2022, outlining policies to improve antibiotic use and appropriateness of antibiotic prescriptions, and including targets for the various specialities in dentistry. Conclusion: Comprehensive National clinical practice and antimicrobial prescribing guidelines, in combination with sensitization campaigns are needed for dental practitioners to effectively combat growing antimicrobial resistance. Keywords: Antimicrobial stewardship, Antimicrobial prescribing, Dentistry, India

Using genomics to examine the persistence of Streptococcus pneumoniae serotype 19A in Ireland and the emergence of a sub-clade associated with vaccine failures

BackgroundStreptococcus pneumoniae serotype 19A remains a significant cause of invasive pneumococcal disease (IPD) in Ireland despite the successful introduction of a 13-valent pneumococcal conjugate vaccine (PCV13) in 2010 which reduced the overall incidence of IPD in children. MethodsInvasive Streptococcus pneumoniae serotype 19A isolates from the Irish reference laboratory between 2007–08 and 2017–18 were analysed using whole genome sequencing (WGS) to investigate the persistence of this vaccine-preventable serotype. We compared the entire national 19A collection to other international collections using a standardised nomenclature of Global Pneumococcal Sequencing Clusters (GPSC). ResultsExpansion of GPSCs and clonal complexes (CCs) may have been associated with vaccine introduction and antimicrobial prescribing policies. A sub-clade of GPSC1-CC320 (n = 25) unique to Ireland, included five of the ten vaccine failures/breakthrough cases identified (p = 0.0086). This sub-clade was not observed in a global GPSC1-CC320 collection. All isolates within the sub-clade (n = 25) contained a galE gene variant rarely observed in a global pneumococcal collection (n = 37/13454, p < 0.001) nor within GPSC1-CC320 (n = 19/227) (p < 0.001). The sub-clade was estimated to have emerged at the start of the PCV-vaccine era (ancestral origin 2000, range 1995–2004) and expanded in Ireland, with most isolated after PCV13 introduction (n = 24/25). ConclusionsThe identification of a sub-clade/variant of serotype 19A highlights the benefit of using WGS to analyse genotypes associated with persistence of a preventable serotype of S. pneumoniae. Particularly as this sub-clade identified was more likely to be associated with IPD in vaccinated children than other 19A genotypes. It is possible that changes to the galE gene, which is involved in capsule production but outside of the capsular polysaccharide biosynthesis locus, may affect bacterial persistence within the population. Discrete changes associated with vaccine-serotype persistence should be further investigated and may inform vaccine strategies.

Antibacterial resistance in ophthalmic infections: a multi-centre analysis across UK care settings

BackgroundBacterial ophthalmic infections are common. Empirical treatment with topical broad-spectrum antibiotics is recommended for severe cases. Antimicrobial resistance (AMR) to agents used for bacterial ophthalmic infections make it increasingly important to consider changing resistance patterns when prescribing, however UK data in this area are lacking. We evaluate the epidemiology and antimicrobial susceptibilities of ophthalmic pathogens across care settings and compare these with local and national antimicrobial prescribing guidelines.MethodsA retrospective, multi-centre observational analysis was undertaken of ophthalmic microbiology isolates between 2009 and 2015 at a centralised North-West London laboratory (incorporating data from primary care and five London teaching hospitals). Data were analysed using descriptive statistics with respect to patient demographics, pathogen distribution (across age-groups and care setting), seasonality, and susceptibility to topical chloramphenicol, moxifloxacin, and fusidic acid.ResultsTwo thousand six hundred eighty-one isolates (n = 2168 patients) were identified. The commonest pathogen in adults was Staphylococcus spp. across primary, secondary, and tertiary care (51.7%; 43.4%; 33.6% respectively) and in children was Haemophilus spp. (34.6%;28.2%;36.6%). AMR was high and increased across care settings for chloramphenicol (11.8%;15.1%;33.8%); moxifloxacin (5.5%;7.6%;25.5%); and fusidic acid (49.6%;53.4%; 58.7%). Pseudomonas spp. was the commonest chloramphenicol-resistant pathogen across all care settings, whilst Haemophilus spp. was the commonest fusidic acid-resistant pathogen across primary and secondary care. More isolates were recorded in spring (31.6%) than any other season, mostly due to a significant rise in Haemophilus spp.ConclusionsWe find UK national and local antimicrobial prescribing policies for ophthalmic infections may not be concordant with the organisms and antimicrobial susceptibilities found in clinical samples. We also find variations in microbial incidence related to patient age, clinical setting, and season. Such variations may have further important implications for prescribing practices and modification of antimicrobial guidelines.

Contrasting patterns of longitudinal population dynamics and antimicrobial resistance mechanisms in two priority bacterial pathogens over 7\xa0years in a single center

BackgroundTwo of the most important pathogens contributing to the global rise in antimicrobial resistance (AMR) are Klebsiella pneumoniae and Enterobacter cloacae. Despite this, most of our knowledge about the changing patterns of disease caused by these two pathogens is based on studies with limited timeframes that provide few insights into their population dynamics or the dynamics in AMR elements that they can carry.ResultsWe investigate the population dynamics of two priority AMR pathogens over 7 years between 2007 and 2012 in a major UK hospital, spanning changes made to UK national antimicrobial prescribing policy in 2007. Between 2006 and 2012, K. pneumoniae showed epidemiological cycles of multi-drug-resistant (MDR) lineages being replaced approximately every 2 years. This contrasted E. cloacae where there was no temporally changing pattern, but a continuous presence of the mixed population.ConclusionsThe differing patterns of clonal replacement and acquisition of mobile elements shows that the flux in the K. pneumoniae population was linked to the introduction of globally recognized MDR clones carrying drug resistance markers on mobile elements. However, E. cloacae carries a chromosomally encoded ampC conferring resistance to front-line treatments and shows that MDR plasmid acquisition in E. cloacae was not indicative of success in the hospital. This led to markedly different dynamics in the AMR populations of these two pathogens and shows that the mechanism of the resistance and its location in the genome or mobile elements is crucial to predict population dynamics of opportunistic pathogens in clinical settings.

Barriers to and enablers of implementing antimicrobial stewardship programs in veterinary practices.

BackgroundAntimicrobial stewardship (AMS) programs are yet to be widely implemented in veterinary practice and medical programs are unlikely to be directly applicable to veterinary settings.ObjectiveTo gain an in‐depth understanding of the factors that influence effective AMS in veterinary practices in Australia.MethodsA concurrent explanatory mixed methods design was used. The quantitative phase of the study consisted of an online questionnaire to assess veterinarians’ attitudes to antimicrobial resistance (AMR) and antimicrobial use in animals, and the extent to which AMS currently is implemented (knowingly or unknowingly). The qualitative phase used semi‐structured interviews to gain an understanding of the barriers to and enablers of AMS in veterinary practices. Data were collected and entered into NVivo v.11, openly coded and analyzed according to mixed methods data analysis principles.ResultsCompanion animal, equine, and bovine veterinarians participated in the study. Veterinary practices rarely had antimicrobial prescribing policies. The key barriers were a lack of AMS governance structures, client expectations and competition between practices, cost of microbiological testing, and lack of access to education, training and AMS resources. The enablers were concern for the role of veterinary antimicrobial use in development of AMR in humans, a sense of pride in the service provided, and preparedness to change prescribing practices.Conclusion and Clinical ImportanceOur study can guide development and establishment of AMS programs in veterinary practices by defining the major issues that influence the prescribing behavior of veterinarians.

The impact of antimicrobial stewardship strategies on antibiotic appropriateness and prescribing behaviours in selected countries in the Middle East: a systematic review.

Antimicrobial resistance is a global health problem and antimicrobial stewardship is an essential component of hospital policies worldwide yet little is known regarding effective implementation strategies in the Middle East. We conducted a review of studies carried out in this region that deployed different antimicrobial stewardship strategies to assess antimicrobial appropriateness and prescribing behaviours. A search of MEDLINE, EMBASE, International Pharmaceutical Abstracts, Google and Google Scholar was conducted. Twenty articles met the inclusion criteria; 2 studies evaluated strategies including prospective audit with feedback, while 18 others evaluated strategies including benchmarking antimicrobial utilization against guidelines. Recommendations for implementation of stewardship in the Middle East highlighted the importance of developing and updating local antimicrobial prescribing policies and using collaborative interdisciplinary approaches for success.

Guidelines in infection prevention: Current challenges and limitations

British Journal of Healthcare ManagementVol. 22, No. 9 CommentGuidelines in infection prevention: Current challenges and limitationsAlison Holmes, Enrique Castro-Sánchez, Raheelah AhmadAlison HolmesSearch for more papers by this author, Enrique Castro-SánchezSearch for more papers by this author, Raheelah AhmadSearch for more papers by this authorAlison Holmes; Enrique Castro-Sánchez; Raheelah AhmadPublished Online:12 Sep 2016https://doi.org/10.12968/bjhc.2016.22.9.440AboutSectionsView articleView Full TextPDF/EPUB ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareShare onFacebookTwitterLinked InEmail View article References Ahmad R, Kyratsis Y, Holmes A (2012) When the user is not the chooser: learning from stakeholder involvement in technology adoption decisions in infection control. 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The authors would also like to acknowledge research produced by Imperial College London and commissioned by the Health Foundation, an independent charity working to continuously improve the quality of healthcare in the UK. Any conclusions, interpretations or policy options may not reflect the commissioner's views. Alison Holmes also acknowledges the support of the Imperial College Healthcare Trust NIHR Biomedical Research Centre.PDF download

CP-061 A cross-sectional survey of the profile and activities of Antimicrobial Management Teams in Irish hospitals

BackgroundSurveillance of antimicrobial prescribing, in order to control the increase in antimicrobial resistance, is recommended by the Guidelines for Antimicrobial Stewardship in Hospitals in Ireland.PurposeTo determine the profile and activities...

CP-139 A cross-sectional survey of antimicrobial stewardship strategies in UK hospitals

BackgroundTo improve prescribing and reduce antimicrobial resistance, antimicrobial stewardship programmes have been implemented in hospitals, usually led by antimicrobial management teams (AMTs). Many of these teams include a hospital pharmacist.PurposeThe...

A cross-sectional survey of the profile and activities of Antimicrobial Management Teams in Irish Hospitals

Surveillance of antimicrobial prescribing, in order to control the increase in antimicrobial resistance, is recommended by the Guidelines for Antimicrobial Stewardship in Hospitals in Ireland. The objective of the study is to determine the profile and activities of Antimicrobial Management Teams (AMTs) in Irish Hospitals by surveying hospital pharmacists. Hospitals in Ireland. A self-completion postal questionnaire was developed from a recent study conducted by members of the authoring team in the United Kingdom, adapted for the Irish context. It was issued to all hospitals in Ireland (n = 70). Differences in responses, using Pearson's Chi squared tests, were evaluated between public and private hospitals to determine whether the funding category had an effect on activities. (1) A profile of AMTs in Ireland. (2) The presence and content of antimicrobial prescribing policies and how adherence to the policies is measured. The response rate was 73 % (n = 51, 71 % public). 57 % (29/51) of hospitals have an antimicrobial management team in place with 93 % (27/29) having a Consultant Medical Microbiologist, 24 % (7/29) having a Consultant in Infectious Diseases and 69 % (20/29) having an Antimicrobial Pharmacist. There is an antimicrobial prescribing policy in place in 88 % (45/51) of hospitals responding. 80 % (36/51) of replies report that the volume of antibiotics prescribed is monitored, 47 % (24/51) conduct audits to measure appropriateness of all antibiotics prescribed and 43 % (22/51) conduct audits of appropriate prescribing of restricted antibiotics. Public hospitals were significantly more likely than private hospitals to review the volume of antibiotics prescribed (p = 0.021) and to audit the appropriateness of restricted antibiotics use (p = 0.003). A lack of resources was reported as the main barrier to antimicrobial surveillance by hospital pharmacists. Around half of Irish hospitals do not have an antimicrobial management team in place but most hospitals have an antimicrobial prescribing policy. Most AMTs have representation by Consultants and Pharmacists, but audit and feedback of antibiotic prescribing activities is limited. Significant differences in audit activities were found between public and private hospitals, with private hospitals performing less well.

Antimicrobial stewardship in Victorian hospitals: a statewide survey to identify current gaps

To determine antimicrobial stewardship (AMS) activities currently being undertaken at Victorian hospitals, identifying gaps when assessed against the Australian Commission on Safety and Quality in Health Care criteria for effective AMS. A survey open to all Victorian health services, conducted between January and March 2012. Availability of the endorsed prescribing guidelines, antimicrobial prescribing policies, formularies, approval systems for restricted antimicrobials, procedures for postprescription review, auditing and selective reporting of sensitivities. Response rates were 96.4% for public health services and 67.7% for private hospitals. Guidelines were available at all public and 88.1% of private hospitals, and 90.6% of public metropolitan, 45.7% of public regional and 21.4% of private hospitals had antimicrobial prescribing policies. Antimicrobial approval systems were used in 93.8% of public metropolitan, 17.3% of public regional and 4.8% of private hospitals. Prescribing audits were conducted by 62.5% of public metropolitan, 35.8% public regional and 52.4% of private hospitals. Nearly all hospitals had selective laboratory reporting of antimicrobial sensitivities. Few hospitals had dedicated funding for AMS personnel. We identified wide differences between hospital AMS activities. Additional support for AMS is particularly required in the public regional and private hospital sectors, principally in the key areas of policy development, antimicrobial approval systems, prescription review and auditing. Further research is required to develop recommendations for implementation of AMS within the regional and private hospital settings.

An analysis of the development and implementation of a smartphone application for the delivery of antimicrobial prescribing policy: lessons learnt

ObjectivesSmartphone usage amongst clinicians is widespread. Yet smartphones are not widely used for the dissemination of policy or as clinical decision support systems. We report here on the development, adoption and implementation process of the Imperial Antimicrobial Prescribing Application across five teaching hospitals in London.MethodsDoctors and clinical pharmacists were recruited to this study, which employed a mixed methods in-depth case-study design with focus groups, structured pre- and post-intervention survey questionnaires and live data on application uptake. The primary outcome measure was uptake of the application by doctors and its acceptability. The development and implementation processes were also mapped.ResultsThe application was downloaded by 40% (376) of junior doctors with smartphones (primary target user group) within the first month and by 100% within 12 months. There was an average of 1900 individual access sessions per month, compared with 221 hits on the Intranet version of the policy. Clinicians (71%) reported that using the application improved their antibiotic knowledge.ConclusionsClinicians rapidly adopted the mobile application for antimicrobial prescribing at the point of care, enabling the policy to reach a much wider audience in comparison with paper- and desktop-based versions of the policy. Organizations seeking to optimize antimicrobial prescribing should consider utilizing mobile technology to deliver point-of-care decision support. The process revealed a series of barriers, which will need to be addressed at individual and organizational levels to ensure safe and high-quality delivery of local policy at the point of care.

Design of antimicrobial stewardship care bundles on the high dependency unit

Antimicrobial guidelines aim to optimise treatment and minimise development of resistance. Care bundles support the implementation of local guidelines. Pharmacist identification of where in the prescribing, monitoring and documentation process, the quality of antimicrobial management in a High Dependency Unit of a large teaching hospital could be improved and design of antimicrobial care bundles for initiation and de-escalation of therapy to standardise care and improve practice. This study was conducted in a 10-bed, mixed medical-surgical HDU in a large Scottish (UK) teaching hospital. Quality indicators (n = 30) were agreed through multidisciplinary team review with reference to the evidence base, national strategy and local policy. Adherence to these quality indicators was measured before and after the pharmacist's contributions. Areas of non-adherence to quality indicators were used to design the care bundles. Adherence to the quality indicators before and after the pharmacist's action. Categorisation of pharmaceutical care issues ('check', 'change in drug therapy' and 'change in drug therapy process') were quantified. From 134 prescriptions, the pharmacist undertook 1,447 actions to ensure adherence to the 30 indicators. Adherence was very good (85.3 % CI 83.5, 87.1), but would have been unsatisfactory (53.5 % CI 50.9, 56.1) without the pharmacist's action (p < 0.001). Change in drug therapy process or change in drug therapy initiated by the pharmacist accounted for 31.9 % (CI 29.5, 34.3) of adherence. Non-adherence was related to documentation of past allergic reactions, bacteriological specimen results, indication and length of course of treatment (both at initiation and de-escalation). Care bundles were designed to target areas of non-adherence to local guidelines. The pharmacist made a significant contribution to improving adherence to evidence based antimicrobial prescribing quality indicators agreed by the multidisciplinary team. Prompts have been identified from the pharmaceutical care process and applied in the design of two antimicrobial care bundles proposed to support adherence with antimicrobial prescribing policies and guidelines.

MRSA prevention strategies and current guidelines

We review prevention strategies to minimise the risk of MRSA soft tissue and bone infections, which can be devastating for the patient and costly for the healthcare provider. Department of Health (England) policy is that screening for emergency admissions will be mandatory from 2011, in addition to existent elective admission screening. Rapid screening technology has not been shown to be cost-effective, meaning that there will be a lag time between admission and the patient's MRSA status being known. Thus, standard infection control policies regarding isolation of high-risk patients will remain, with a continuing focus on MRSA decolonisation, aimed at minimising the risks of auto-infection and transmission to other patients. Antimicrobial prescribing policies should be designed to take into account the local burden of resistant organisms, but also minimise unnecessary antibiotic use. There is an increasing realisation that reducing the use of fluoroquinolones and third-generation cephalosporins (which have been associated with increased carriage of MRSA) in patient populations where MRSA is prevalent can be a useful control measure. Prevention of orthopaedic infections clearly involves general operating theatre protocols, such as suitable antiseptic skin preparation, and additional measures including the use of laminar airflow. Antibiotic prophylaxis is adjusted in patients known to have MRSA to include a glycopeptide, and local guidelines may adopt such regimens for all patients due to the burden of MRSA in the local patient population. A future development that may have an effect on practice is the development of a Staphylococcus aureus vaccine, which has been shown to be cost-effective in a computer-modelled evaluation.

1260 Design of Electronic Software to Aid Rationalised Antibiotic Prescription and Implementation of the Local Antibiotics Policies.

Antimicrobial resistance has become a global public health problem. The overuse (or misuse) of antimicrobials resulting partly from poor prescribing behaviour, is the single most important determinant of resistance. As a result of ongoing concern regarding antimicrobials resistance, the UK Department of Health in 2003 allocated £12 million to be spent over 3 years on developing roles for pharmacists taking a lead in promoting rational antibiotic prescribing. Implementation of standard treatment guidelines for acute infections and essential drug lists are powerful mechanisms to improve prescription practices. Aims: To design an easy-to-use, user-friendly desktop windows application for all prescribing professionals acting as quick reference for the implementation of the local antibiotics guidelines and essential drug lists. Methods: The designed software is based on antimicrobial guideline locally available in most hospitals. It is intuitively easy to use and requires no advanced computer skills. Figure Results: The software provides dosage recommendations for patients of different age groups based on the British National Formulary. It aids selection of appropriate antibiotics based on agreed priority criteria for selected common disease conditions. It minimises prescribing errors by aiding in calculation of the correct antimicrobial dosage based on the given patient's weight. It enables prescribers to easily implement the local antibiotics guidelines. Conclusion: We have designed an easy-to use simple electronic assistant which offers guidance on choice and priority of antibiotics prescribed for empiric management of selected disease conditions within the context of a local antimicrobial prescribing policy.

Antimicrobial prescribing policy and practice in Scotland: recommendations for good antimicrobial practice in acute hospitals

This guidance document on prudent use of antibiotics and other antimicrobial drugs has been produced for NHSScotland by the Scottish Medicines Consortium (SMC). It fulfils one of the requirements set out in the Antimicrobial Resistance Strategy and Scottish Action Plan (Scottish Executive Health Department 2002) and forms part of the Healthcare Associated Infection (HAI) Action Plan work programme overseen by the Ministerial HAI Task Force. The objective was the development of a set of Good Practice Recommendations for Antimicrobial Prescribing in Hospitals to be implemented at the national or local level. The publication of the recommendations of this document in the Journal of Antimicrobial Chemotherapy (JAC) aims to highlight the value of such a national framework to a broader national and international community, particularly aimed at those decision-makers involved in antimicrobial stewardship. While some of its content may only be applicable to a devolved Scottish Health Care system we feel that many of the principles and good practice points are of generic concern and would be of relevance and value to all acute hospitals. On behalf of the all the authors involved in producing this document it is our hope that this article will stimulate debate and action within our acute hospitals.